Optimal surgical procedure for treating early-stage adenoid cystic carcinoma of the breast

To explore the superiority of breast conservation surgery (BCS) to mastectomy in treating early-stage adenoid cystic carcinoma of the breast (BACC). Patients with surgically treated stage I/II BACC were enrolled between 2000 and 2019 in the SEER database; they were divided into the BCS and mastectomy groups. Overall survival (OS) and disease-specific survival (DSS) were compared between the two groups, and Cox hazard regression models were used to determine the independent predictors. Of the 583 patients in the study, 386 were included in the BCS group. The 10-year OS rates for the BCS and mastectomy groups were 78% (95% CI: 74–82%) and 76% (95% CI: 70–82%), respectively, but the difference was not statistically significant (p = 0.968). The 10-year DSS rates for the BCS and mastectomy groups were 95% (95% CI: 93–97%) and 89% (95% CI: 85–93%), respectively, and the difference was statistically significant (p = 0.002). Pathological examination of regional lymph nodes and adjuvant treatment were not associated with improved OS or DSS, but age, disease grade, and lymph node metastasis were independent prognostic factors. For stage I/II BACC, BCS can achieve more satisfactory 10-year OS and DSS than mastectomy.


Results
Baseline data. Overall, 583 patients were included in the analysis; of these, 6 were men and 577 were women, with a mean age of 68.5 ± 20.5 years. A total of 386 patients received BCS and 197 patients did not. Both groups had similar distributions of age, sex, marriage, race, side, chemotherapy, and other criteria (all p > 0.05). However, 62.1% and 9.1% of patients in the BCS and mastectomy groups, respectively, underwent radiotherapy, and the difference was statistically significant (p < 0.001). Patients in the BCS group were more likely to undergo lymph node examination (p < 0.001). Compared to 54.3% in the mastectomy group, the BCS group had a lower rate (37.0%) of stage II (p < 0.001). Higher pathologic grade was more commonly seen in the mastectomy group (p < 0.001) ( Table 1).
Overall survival. OS showed different trends among different age subgroups (Fig. 1); patients aged 45-59 years had the best OS with a 10-year rate of 94% (95% CI: 91%-99%), and patients aged more than 75 years had the poorest survival with a 10-year rate of 36% (95% CI: 24-48%). Grade III/IV patients had a Subgroup analysis of OS. The 10-year OS rates for the BCS and mastectomy groups were 78% (95% CI: 74-82%) and 76% (95% CI: 70-82%), respectively; the difference was not statistically significant (   93-97%) and 89% (95% CI: 85-93%), respectively, and the difference was statistically significant (Fig. 4B, p = 0.002). The significance of age, grade, chemotherapy, lymph node metastasis, and HER 2 in influencing DSS was also noted in univariate Cox analysis. Additional multivariate analysis confirmed the independence of age 45-59 years and BCS in improving DSS and that of grade III/IV disease and lymph node metastasis in decreasing DSS (Table 3).

Discussion
This study intended to explore the optimal management of stage I/II BACC, and the most important finding was that BCS could achieve comparable OS to and better DSS than other surgical procedures; pathological examination of regional lymph nodes or adjuvant treatment did not provide an additional survival benefit. This study clarified that BCS alone might be sufficient for treating stage I/II BACC without compromising the prognosis. There has been considerable progress in breast cancer treatment in recent years, and BCS has become an attractive alternative therapy option for early-stage breast cancer 17 . Saifi et al. 18 compared OS and DSS between BCS and mastectomy cohorts in stage I/II triple-negative breast cancer using the SEER database and found that BCS patients had 5-year OS and DSS rates of 89% and 93%, respectively, which were both significantly higher than those in mastectomy group. Chu et al. 19 also reported that the 10-year OS and DSS were better among those who underwent BCS (OS: 80.0%; DSS: 92.7%) than among those who underwent mastectomy (OS: 69.3%; DSS: 88.8%). Even after controlling for co-factors, mastectomy was associated with a 29.8% increased risk of cancer-specific death and a 28.6% increased risk of overall death. van Maaren et al. 20 reported that the BCS and mastectomy groups showed equal 10-year OS, DSS, and distant metastasis-free survival in T1-2N2 breast cancer, and after stratification, improved OS and DSS were noted in patients with T2N2 disease. Similar findings were also reported in other studies 21,22 . These reports suggest that BCS did not worsen the oncologic prognosis, at least for early-stage breast cancer; however, most BACC cases were triple-negative but had different biological behaviors from classic breast cancer, which then raised the question of whether the same conclusion could apply to BACC. The current study might be the first to report that the two groups showed similar OS, but better DSS with BCS, suggesting the superiority of BCS in treating BACC.
Lymph node metastasis is an adverse pathological feature and predicts a worse prognosis for most cancers [23][24][25] . The current study supports this viewpoint; lymph node metastasis is related to a nearly fourfold increased risk of overall death and a 6.5-fold increased risk of cancer-caused death. Therefore, timely detection of occult metastasis is important to achieve better regional control. BACC is associated with low lymph node metastasis; no positive lymph nodes were found in six cases in a report by Treitl et al. 6 . Moreover, in a multicenter study of 31 patients who underwent axillary lymph node dissection, only 2 patients had pathological metastases 26 ; this is also supported by our findings. Compared to observation, pathological examination of regional lymph nodes did not provide any survival benefit. No similar literature was available for comparison, but we speculated that the finding was contributed to by two factors: one was the low possibility of lymph node metastasis, and another was that the main cause of death was distant metastasis but not regional metastasis 27 .   www.nature.com/scientificreports/ Owing to the key role of age in prognosis, it was suggested that "age" should be added to a future edition of the AJCC Breast Cancer Staging Manual 28 . A previous study proposed that early-onset breast cancer tended to show adverse features of high grade, triple-negativity, multifocality, and a high proliferation index, translating into worse survival in young patients 29 . Young patients also tended to have a higher number of metastatic sites 30 . However, Berliner et al. 's study found contradicting results 31 . The authors enrolled 174 consecutive patients with breast cancer with central nervous system involvement and divided them into two groups with an age cutoff of 45 years. They reported that the younger group was characterized by longer OS in the entire population and longer DSS in a subgroup of triple-negative breast cancer. All the findings indicated that the role of age remained to be further clarified. In the current study, patients aged 45-59 years had the best OS and DSS among 4 different age subgroups. This finding might be explained by the fact that patients aged 45-59 years had better health status than older patients and tolerated aggressive treatment better. Moreover, as patients aged 45-59 years were usually at the zenith of their careers, economic superiority afforded them better medical resources.
The survival significance of pathologic grade has been widely analyzed. BACC is triple-negative, and triplenegative breast cancer usually carries a poor prognosis and requires systemic chemotherapy. However, BACC is heterogeneous with the presence of transcriptional, marked genetic, clinical, and histologic differences, ranging from low to high grade 32 , histology grade III-IV was related to the hazard of mortality increased, and indicator of adjuvant treatment, although whether adjuvant therapy could optimize the prognosis of patients at high-risk remained a concern 7,8 . However, patients with high-grade cancer have a clinically satisfactory prognosis, which may be explained by the phenomenon found in salivary gland adenoid cystic cancer: distant metastasis was the most common type of treatment failure, but it still maintained a relatively slow growth rate 27 .
Some limitations in the current study must be acknowledged: the SEER database is prone to selection bias. We cannot determine why a patient received nodal sampling, mastectomy, BCS, or adjuvant therapy. Moreover, www.nature.com/scientificreports/ as data on lymphovascular invasion, margin status, and treatment intent could not be obtained, it might have affected the survival outcome.
In conclusion, for patients with stage I/II BACC, BCS could provide satisfactory 10-year OS and DSS. Pathological examination of regional lymph nodes and adjuvant treatment did not provide an apparent survival benefit; age, disease grade, and lymph node metastasis were the most important prognostic factors.

Data availability
All data generated or analyzed during this study are included in this published article. And the primary data could be achieved from the corresponding author.